Behavioural and Cognitive Psychotherapy, 2015, 43, 676–691

First published online 13 February 2014 doi:10.1017/S1352465813001124

A Service Evaluation of a 1-Year Dialectical Behaviour

Therapy Programme for Women with Borderline Personality
Disorder in a Low Secure Unit

Emily Fox, Kirsten Krawczyk and Jessica Staniford

St Andrew’s Healthcare, Northampton, UK

Geoffrey L. Dickens

St Andrew’s Academic Centre, King’s College London, Northampton, UK

Background: Previous studies about the effectiveness of Dialectical Behaviour Therapy for
the treatment of Borderline Personality Disorder have had promising results. However, no
previous studies have examined its effectiveness when delivered in low secure inpatient
services for women. Aims: To evaluate clinical outcomes during and after a 1-year period
of admission within a low secure unit for women offering a Dialectical Behaviour Therapy
programme. Method: A naturalistic, within subjects study of clinical data collected as part
of routine practice was conducted. Participants were18 consecutively admitted women who
met the diagnostic criteria for Borderline Personality Disorder and had completed at least
1 year of treatment. Measures covered: risk behaviours; self-reported symptoms of Borderline
Personality Disorder, and current mood and symptom experience; staff reports of clinical
problems, needs and social functioning. Scores were compared between admission and at
6 months and 1 year. Results: There was a statistically significant improvement on all
13 measures over the year’s treatment. Most improvement was demonstrated between
admission and 6 months. Conclusions: Engagement in1-year’s treatment was associated with
significant reduction in risk behaviours and both staff-rated and self-rated outcome measures.
Some significant questions remain about which elements of the programme are most effective
but the results are encouraging.
Keywords: Borderline Personality Disorder, dialectical behaviour therapy, low secure,
women’s service, service evaluation.

Introduction
Borderline Personality Disorder (BPD) is a pervasive and complex personality disorder that
is characterized by significant instability of interpersonal relationships, self-image, mood,
and impulsive behaviour (American Psychiatric Association, 1994). Affected individuals can
engage in a pattern of sometimes rapid fluctuation “from periods of confidence to despair,

Reprint requests to Emily Fox, St Andrew’s Healthcare, Women’s Service Psychology, Billing Road, Northampton
NN1 5DG, UK. E-mail: efox@standrew.co.uk

© British Association for Behavioural and Cognitive Psychotherapies 2014

 Evaluation of low secure DBT treatment 677

with fear of abandonment and rejection, and a strong tendency towards suicidal thinking and
self-harm. Transient psychotic symptoms, including brief delusions and hallucinations, may
also be present” (National Collaborating Centre for Mental Health [NCMH], 2009: p. 15).
Diagnosis is associated with substantial impairment of social, psychological and occupational
functioning and reduced quality of life. Many people with BPD persistently self-harm and
there is an increased risk of suicide (Paris and Zweig-Frank, 2001). Coid, Yang, Tyrer, Roberts
and Ullrich (2006) report that 4.4% (95% C.I. 2.9–6.7) of the British population meet the
diagnostic criteria for any personality disorder; prevalence of BPD was calculated as 0.7%
(95% C.I. 0.3–1.7). Annual societal cost of BPD has been estimated at around €17,000 per
individual with 22% of this being related to direct healthcare costs (van Asselt, Dirksen, Arntz
and Severens, 2007).
Snowden and Kane (2003: p. 41) have described treatment provision for this group as
“patchy”. However, there have been some significant developments in England and Wales
in the treatments available to people with BPD and in the attitudes of care providers in
recent years. The National Institute for Mental Health in England (2003a, b) have produced
policy guidance on developing services for people with personality disorder: Personality
Disorder: no longer a diagnosis of exclusion; and the implementation of the policy as cited
in the Personality Disorder Capabilities Framework (Department of Health, 2003). These
documents were significant in addressing the issues of meeting the needs of people with
BPD and sent a clear message that services for those with personality disorders needed to
be developed and expanded. National guidelines (the NICE Guideline) on the treatment and
management of BPD were published in 2009 (NCMH, 2009).
Psychological approaches to the treatment of BPD have been developing for the past three
decades. From the 1980s clinicians began to adapt standard cognitive therapy to meet the
needs of patients presenting with personality disorders (Linehan, Armstrong, Suarez, Allmon
and Heard, 1991; Ryle, 1997; Davidson, 2000). Further, evaluations of Mentalization-Based
Treatment (Bateman and Fonagy, 1999) and transference-focused psychotherapy (Doering
et al., 2010) have demonstrated that psychological treatments are effective compared with
treatment as usual.
Dialectical Behaviour Therapy (DBT) is a psychological approach designed to treat
chronically suicidal individuals with BPD (Linehan et al., 1991). Linehan’s development of
the approach (1993a, b) recognized the need to balance Eastern practices of mindfulness
and acceptance with Western psychological procedures of change. A comprehensive DBT
programme includes five modes: enhancing capabilities; enhancing motivation; ensuring
generalization of skills; structuring the environment; and enhancing therapists capabilities
and motivation to deliver the treatment effectively (Linehan, 1993a). The NICE Guideline for
BPD (2009) recommends a comprehensive DBT programme for women with BPD “for whom
reducing recurrent self-harm is a priority” (NCMH, 2009: p. 384).
A number of randomized controlled trials (Linehan et al., 1991; Linehan, Heard and
Armstrong, 1993; Koons et al., 2001; Verheul et al., 2003; Linehan et al., 2006) of DBT
delivered in outpatient settings have demonstrated a reduction in parasuicidal behaviours;
patients were more likely to complete treatment and spent fewer days in inpatient services
when compared to treatment as usual controls. Koons et al. (2001) also reported statistically
greater reductions in depression, hopelessness and anger among BPD patients receiving DBT
compared with a treatment as usual group, despite reducing the length of treatment from
12 to 6 months.
678 E. Fox et al.

DBT has also been applied in inpatient programmes (Swenson, Sanderson, Dulit and
Linehan, 2001; Bohus et al., 2004). The only randomized-controlled trial (Bohus et al., 2004)
that delivered a comprehensive inpatient DBT programme compared patients completing a 3-
month programme within an inpatient setting and those placed on a waiting list and receiving
treatment as usual in the community. Whilst there was no significant change on any outcome
measure at 4-month assessment for waiting list individuals, analysis of the DBT treatment
group revealed significant positive changes in the psychological variables and a significant
reduction in self-harm. Further, the DBT treatment group improved significantly more on
seven of the nine variables analyzed including ratings of depression, anxiety and interpersonal
functioning.
A further uncontrolled study, completed by Low, Jones, Duggan, Power and MacLeod
(2001), assessed the effectiveness of a 1-year DBT programme for patients detained in a
UK high secure hospital. During the 12 months of treatment the self-harm rates, measured at
3-month blocks during therapy and 6 months after therapy, reduced significantly and this
reduction was sustained at the 6-month follow-up. These behavioural changes paralleled
significant reductions in dissociative experiences and increased coping beliefs. Self-reported
symptoms of depression, impulsivity and suicidal intent also reduced in severity.
In summary, evaluation of DBT programmes has been reported across a range of
community and inpatient settings. Both community and inpatient programmes have achieved
significant reductions in parasuicidal behaviours when compared with waiting list or treatment
as usual. Further, groups receiving DBT have significantly improved on measures of
depression, anxiety and interpersonal relationship functioning. While DBT delivery has been
researched in a high secure setting (Low et al., 2001) the current study considers DBT
treatment in a low secure setting, which is an under researched area. Moreover, in the current
study setting patients can recommit to the DBT programme and stay in treatment, after one
year. Further evidence is required to evidence the effectiveness of DBT when delivered in a
low secure service for female patients with BPD.

Method
Design
This naturalistic evaluation of treatment in a low secure women’s service used a within-groups
design to compare data collected on admission, at 6 months and after 1 year’s treatment. Data
were collated from archived and active files. All patients are informed at admission (in the
unit’s information pack) and when the routine measures are collected that clinical data may
be used for audit and evaluation of the service.

Setting and participants

The participants were N = 18 women who were admitted consecutively to the low secure
women’s DBT unit within a large charitable psychiatric hospital between December 2007 and
March 2011 (see Table 1 for characteristics). Low secure units are intended for individuals
who are detained under the Mental Health Act and who pose a definable clinical risk to others
and/or present with challenging behaviours that may include self-harm. Patients do not pose
the level of grave and immediate danger or serious danger to the public that requires high or
 Evaluation of low secure DBT treatment 679

Table 1. Patient characteristics (N = 18)

Characteristic n (%) M (SD) Range
Age in years: 29.0 (9.0) 18–45
Age of first contact with mental health services 18.7 (8.4) 8–27
Education:
Further Education 5 (28)
A-Levels 2 (11)
GCSEs 7 (39)
No formal qualifications 4 (22)
Referral source:
Medium secure 5 (28)
Low secure 7 (39)
Psychiatric Intensive Care Unit 6 (33)
Section of Mental Health Act (1983 amended 2007):
Section 3 16 (89)
Section 37 1 (6)
Section 47/49 1 (6)
Experience of abuse:
Experienced childhood sexual abuse 14 (78)
Police involvement:
Conviction 6 (33)
Police caution 2 (11)
Police involvement but no action 2 (11)
No police involvement 8 (44)

medium secure care. A range of physical, procedural and relational security measures are used
to ensure that risk can be managed and rehabilitation measures implemented within a safe and
secure environment (Royal College of Psychiatrists Centre for Quality Improvement, 2010).
The mean length of stay for patients in the current service is 2.1 years (range 10 months to
4.1 years). To be admitted to the Unit all women had to meet the diagnostic criteria for BPD, be
free from any additional mental illness (World Health Organization, 1992; American Psychi-
atric Association, 1994), and willing to commit to the DBT programme. All the women were
detained under Part II of the Mental Health Act (1983 amended 2007), most (n = 16, 89%) un-
der a civil commitment, with the remaining two women detained under forensic commitment.
The women admitted were referred to a specialist low secure unit because their presenting
risk behaviours required enhanced physical security for their safe management. Information
gathered from pre-admission assessment forms and case notes indicated that all patients had
a history of suicidal or self-injurious behaviour (see Figure 1). All patients had a history
that included at least one act of physical or verbal aggression either in the community or a
psychiatric hospital setting (see Figure 2); incidents prior to admission included assault, fire-
setting and possession and use of weapons. The previous convictions and cautions included:
breach of the peace; common assault; criminal damage; resisting arrest; and shoplifting.

Dialectical-Behavioural Therapy (DBT) intervention

The psychological component of the programme in this study is a comprehensive DBT
programme as described by Linehan (1993b). A comprehensive DBT programme provides
680 E. Fox et al.

Figure 1. (Colour online) Pre-admission of self-injurious behaviour

Figure 2. (Colour online) Pre-admission aggressive behaviour

 Evaluation of low secure DBT treatment 681

five functions: structuring the environment; enhancing the patient’s capabilities; improving
patient’s motivation; generalizing the DBT skills to the environment; enhancing capabilities
and improving motivation for staff. The modes that are typically used to deliver the five
functions include: skills training groups comprising four modules run over 6 months (Core
Mindfulness, Emotion Regulation, Interpersonal Effectiveness, Distress Tolerance; Linehan,
1993b); individual therapy sessions; unscheduled/telephone skills coaching; structuring
the patient’s environment (e.g. psychoeducation or family/couple therapy); and weekly
consultation for the therapists delivering the treatment (Linehan, 1993a). All five functions
of a comprehensive DBT treatment programme are delivered in the current study setting; the
treatment modes adapted in the current study are described below. All therapists were trained
at Intensive Level (10 days) or Foundational Level (5 days) in DBT with Behavioural Tech,
LLC, the certified trainers of DBT. Further, two therapists have had a minimum of 20 hours
supervised practice; both were rated as adherent.
A number of adaptations have been made to the programme, originally developed for
community use, to increase its suitability for the secure environment. Rather than weekly
skills training groups, patients receive hour long twice-weekly DBT skills training groups
(enhancing capabilities). However, as in the standard outpatient DBT programme, all patients
included in the study had completed the four DBT Skills Training modules twice over the
12-month treatment period. There is a further adaptation to meet the function of ensuring
generalization of skills to the current environment. In an outpatient setting clients tend to
telephone their therapist in order to receive skills coaching. In the current setting patients
have contact telephone numbers of their primary DBT therapist but can also request skills
coaching if they see their therapist on the unit. During their therapist’s working hours
patients are able to contact them directly for skills coaching. If the primary therapist is out
of the hospital patients are then able to contact any of the other DBT therapists for skills
coaching. The modalities of the DBT programme that are unchanged from a community
setting are the weekly individual DBT sessions (improving/enhancing motivation) and the
weekly DBT consultation for therapists (enhancing therapists’ capabilities and motivation to
treat effectively).
The final function of structuring the environment is articulated in the unit’s Operational
Policy and includes a risk management structure, an incentive programme, staff training in
behavioural principles, physical exercise sessions, and nurse-led recreational activities (see
Long, Fulton and Hollin, 2008 for further exposition) and an occupational therapy programme
(see Lee and Harris, 2010 for details).
As with standard DBT both the patient and the therapist make explicit commitments.
Patients commit to remain in therapy for an agreed length of time, to attend scheduled sessions
and to work on problems including reducing suicidal and violent behaviours (Stage I DBT
treatment). Therapists commit to make themselves available for weekly sessions, to offer skills
coaching, to keep the contents of the session confidential and to make every effort to conduct
effective therapy (Palmer, 2002).

Measures
The instruments used were validated measures used as part of routine outcome evaluation.
They were selected by the clinical team on the basis of their proven validity, acceptability to
the patients and ease of administration.
682 E. Fox et al.

Overt Aggression Scale (OAS; Yudofsky, Silver, Jackson, Endicott and Williams, 1986).
Throughout the patients’ stay on the unit all episodes of risk behaviour are collated through
observation and self-disclosure and scored using the OAS. The OAS measures four categories
of aggression (verbal aggression, physical aggression against objects, physical aggression
against self and physical aggression against others) on a severity scale from 1 (least severe)
to 4 (most severe). We adopted the process described by Kay, Wolkenfield and Murrill (1988)
where scores for acts of verbal aggression, physical aggression against objects, physical
aggression against self and physical aggression against others are multiplied by one, two, three
and four respectively. This adds weight to the most severe aggressive behaviour. For purposes
of analysis we then collapsed OAS data put into two categories: 1) physical aggression against
self (summed and weighted total of the aggression against self subscale) and 2) externally
directed aggression (summed weighted total of verbal aggression, aggression against objects
and aggression against people categories).
OAS scores were collated for all instances of aggression to self and others during the first
4 weeks of admission (T0), then all instances of aggression to self and others during month
6 (T1) and during month 12 (T2) following admission. Incidents of aggression are routinely
collected by nursing staff when they occur and then collated on a weekly basis by the assistant
psychologist.

Global Assessment of Functioning (GAF; American Psychiatric Association, 2000).

The GAF was completed at three time periods spanning 12 months: at admission, at 6
months and at 12 months. The GAF is a multiaxial evaluation of severity of disturbance
and adequacy of social functioning. The GAF is scored on a scale from 1–100 where 100
represents positive mental health and 1 a complete inability to function in society. A score of
70–100 reflects scores obtained by the average population, 30–70 is typical of the psychiatric
out-patient population, and 0–40 is typical of the psychiatric inpatient population.

Brief Psychiatric Rating Scale (BPRS; Ventura, Green, Shaner and Liberman, 1993).
The BPRS is a measure of current mood and symptom experience. The BPRS consists of
24 symptom constructs, 14 are self-reported (reflecting the last 4 weeks) and 10 are rated by
clinical observations of the patient’s behaviour during the interview. Each item is rated on a 7-
point scale from (1) not present to (7) extremely severe and a total pathology score is derived
by summing individual item totals. It was completed by the clinical team and self-reported at
3 time periods spanning 12 months. Leucht et al. (2005) have reported that a BPRS total score
of 31 corresponds to a rating of “mildly ill” on the Clinical Global Impressions Scale (CGI;
Guy, 1976). Further, percentage improvements of 58% on the BPRS correspond to a rating of
“much improved” on the CGI (Leucht et al., 2005).

Camberwell Assessment of Need – Forensic Short Version (CANFOR-S; Thomas, Harty,

Parrott, McCrone, Slade and Thornicroft, 2003). The CANFOR-S is a semi-structured
interview schedule that assesses need in 25 domains of a person’s life. Items relate to problems
experienced by the patient during the past month and whether they have received sufficient
help or support. Each domain is then scored as a “met” or “unmet” need, each met or unmet
need contributing a score of one towards two subtotals. For the purpose of this study, the
clinical team’s ratings of met and unmet needs as defined by the CANFOR-S were analyzed
at three time periods spanning the 12-month study period. Staff ratings were used since this
rates the interventions/support provided rather than engagement in interventions or support.
 Evaluation of low secure DBT treatment 683

However, substantial agreement has previously been reported between staff and patient ratings
in secure mental health care (Long, Webster, Waine, Motala and Hollin, 2008).

Health of the Nation Outcomes Scales for users of secure and forensic services (HoNOS-
secure; Sugarman and Walker, 2007). HoNOS-secure was completed at three time points
during the study. HoNOS-secure comprises 12 symptom and functioning items that are very
similar to the original HoNOS (Wing et al., 1998). An additional 7-item “security scale”
measures current need for secure care. All seven items are rated on a criterion-referenced
4-point Likert scale. The HoNOS-secure has acceptable inter-rater reliability (Dickens,
Sugarman and Walker, 2007).

Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD; Zanarini, 2003).
On admission and then at 12 months from admission each participant completed the ZAN-
BPD. The ZAN-BPD is a self-report measurement of BPD symptom severity over the previous
2 weeks. The measure contains nine diagnostic DSM-IV (APA, 1994) criteria for BPD. All
criteria are rated on a scale of 0 (no symptoms) to 4 (severe symptoms) according to the
rating guidelines. The nine criteria scores are used to create four subscale scores relating
to Affective Disturbance (total score for anger, moodiness and emptiness items), Cognitive
Disturbance (total scores for identity disturbance and distrust/suspiciousness/dissociation
items), Impulsivity (total score for self-mutilation/suicidality and other forms of impulsivity
items) and Disturbed Relationship (total score of efforts to avoid abandonment and unstable
relationships items). ZAN-BPD has established reliability and validity and is sensitive to
change (Zanarini, 2003).

Data analysis
Data were entered into PASW Statistics 18 for Windows (2011). Within subjects comparisons
were made between measures taken at admission (T0), 6 months (T1) and 12 months (T2)
following admission. The sole exception was the ZAN-BPD, which was rated at just two
time points (admission and 12 months). Data were treated as ordinal and appropriate non-
parametric tests were used. For measures taken at three time periods Friedman’s Tests were
conducted and post hoc analysis using Wilcoxon signed ranks tests were undertaken to
confirm differences between specific time periods. Wilcoxon signed ranks tests were also
used for the measure taken only at two time periods. Alpha was set at p = .05 for the
test conducted at two time periods. For those conducted at three time periods Bonferroni
correction for multiple testing was employed and alpha was consequently set at p = .017.
For statistically significant results effect size (r) was calculated as recommended for the non-
parametric Wilcoxon test in the literature (Hirsch, Keller, Albohn-Kühne, Kroner and Donner-
Banzhoff, 2011). Cohen (1988) has recommended that effect size r be interpreted thus: r =
0.1, small effect size; r = 0.3, medium effect size; r = 0.5, large effect size.

Ethical considerations
The study was approved by local audit and research committees who advised that it constituted
a service evaluation that did not require formal ethics approval nor individual participant
consent for analysis of routinely collected and anonymized data.
684 E. Fox et al.

Results
Overt Aggression Scale
Table 2 shows that there was a statistically significant reduction in both self-harm and
externally directed aggression (verbal aggression and physical aggression against objects and
people) as rated on the OAS over the 12-month period of admission. While both self-harm and
external aggression reduced considerably between the time periods T0 and T1 this was not
statistically significant. Effect size of the reduction for both self-harm and externally directed
aggression was r = 0.44 indicating a moderate effect size.

Global Assessment of Functioning

GAF scores increased significantly between admission and 6 months and a large effect size
(r = −0.62) was evident. Although GAF scores changed significantly between admission
and 12 months there was no significant change in the second period. This suggests that
improvement as measured by the GAF was mostly confined to the first 6 months of admission.

Brief Psychiatric Rating Scale

BPRS scores reduced significantly between admission and 6 months and a large effect size
(r = 0.54) was evident. Improvements in symptoms measured on the BPRS appear to have
occurred mostly in the first 6 months of admission.

Camberwell Assessment of Need – Forensic Short Version

Met needs. Scores for met needs increased significantly over the first 6 months of
admission, a moderate effect size (r = −0.45) was evident. There was no further significant
improvement in scores over the subsequent admission period and most change therefore
occurred in the first 6 months of treatment.

Unmet needs. Scores for unmet needs decreased significantly over the first 6 months of
admission (moderate effect size, r = −0.45). The score for unmet needs did not subsequently
change.

Health of the Nation Outcomes Scales

HoNOS scores decreased, indicating improvement, over the whole 12-month period of
admission; a moderate effect size was evident (r = −0.49). Non-significant trends towards
improvement were apparent in both time periods.

Health of the Nation Outcomes Scales for users of secure and forensic services
HoNOS-secure scores reduced significantly over the whole 12-month period of admission
(small effect size, r = −0.23). There was evidence that most change occurred in the second
6-month period of admission where change was significant (moderate effect size, r = −0.48).
 Table 2. Change over the course of 1-year DBT treatment
T0 T1 T2 Friedman test Wilcoxon T0-T1 Wilcoxon T0-T2 Wilcoxon T1-T2
Measure Subscale M (SD) M (SD) M (SD) p p (r) p (r) p (r)
OAS Self-harm 27.9 (46.6) 10.1 (22.9) 1.8 (4.3) 0.000 0.059 0.008∗ (−0.44) 0.063
External 10.6 (15.1) 4.2 (10.2) 0.6 (1.3) 0.003 0.034 0.008∗ (−0.44) 0.138

Evaluation of low secure DBT treatment

aggression
GAF 5.7 (3.8) 13.3 (5.6) 16.5 (5.5) 0.000 0.000∗ (−0.62) 0.000∗ (−0.62) 0.032
BPRS 35.2 (14.5) 19.7 (10.9) 18.5 (11.9) 0.004 0.001∗ (−0.54) 0.002∗ (−0.52) 0.355
CANFOR-S Met needs 12.1 (5.6) 16.6 (3.4) 17.5 (3.6) 0.002 0.007∗ (−0.45) 0.005∗ (−0.47) 0.344
Unmet needs 4.8 (4.9) 1.5 (1.7) 1.2 (4.0) 0.001 0.006∗ (−0.45) 0.023 0.107
HoNOS-secure Symptoms 17.2 (2.9) 16.4 (3.7) 14.8 (1.5) 0.007 0.057 0.003∗ (−0.49) 0.044
Security 16.8 (2.9) 15.8 (2.9) 14.5 (2.0) 0.000 0.170 0.001∗ (−0.23) 0.004∗ (−0.48)
ZAN-BPD 17.2 (6.7) 8.2 (6.6) 0.003∗∗ (−0.49)
Affective 5.7 (2.6) 3.4 (2.7) 0.019∗∗ (−0.39)
disturbance
Cognitive 4.1 (2.1) 2.1 (2.1) 0.019∗∗ (−0.39)
disturbance
Impulsivity 4.1 (2.8) 1.3 (1.8) 0.005∗∗ (−0.47)
Disturbed 3.2 (1.9) 1.3 (1.3) 0.005∗∗ (−0.46)
relationships

Notes: T0 = baseline admission data, T1 = 6 month data, T2 = 12 month data. Bold text signifies statistically significant result following Bonferroni
correction for multiple testing. r = effect size (Pearson’s correlation)
∗
p<.05, ∗∗ p<.01, ∗∗∗ p<.001

685
686 E. Fox et al.

Zanarini Rating Scale for Borderline Personality Disorder

ZAN-BPD total scores fell significantly between admission and 12 months, a moderate effect
size (r = −0.49) was evident. There was significant change on all four subscales with
moderate effect sizes on each: affective disturbance (r = 0.39); cognitive disturbance (r =
0.39); impulsivity (r = 0.47) and disturbed relationships (r = 0.46).

Discussion
The aim of the current study was to evaluate outcomes for women diagnosed with BPD
during and after 1 year’s treatment in a low secure service offering a DBT programme. The
programme was associated with statistically significant positive change on all measures and
all subscales of each measure used. Treatment effect sizes were moderate with the exception
of two large effect sizes, for the GAF and BPRS, and one small effect size (HoNOS-secure).
There was significant improvement on clinician rated symptomatology and on self-reported
symptoms, and on measures of social functioning and security need. Moderate and large
effect sizes effects were observed for self-reported measures of symptomatology (ZAN-BPD
and BPRS respectively). Clinician rated symptomatology was supported by self-reports with
medium effect size being observed for HoNOS symptoms and GAF scores. In addition,
measures of met and unmet needs (CANFOR-S) provided a moderate effect size. These
behaviours and symptomatic improvements were reflected in the reduction of the HoNOS
secure ratings, over time, with a medium effect size being observed. Much of the significant
change for these items was recorded in the first 6 months of admission. However, non
statistically significant positive trends on GAF and HoNOS scores continued in the second
half of the admission.
Observed aggression also reduced over the period of treatment, both for self-harm and
for verbal and physical aggression directed at objects and people. Interestingly, although
observed aggression fell across both categories in the early part of admission, this did not
achieve statistical significance until the second half of the evaluation period. This suggests that
improvements in behaviour continued beyond the initial 6-month period and that they lagged
behind more immediate gains in symptomatology and social functioning. This is supported
by the finding that the level of security need as rated by the team on the HoNOS-secure only
fell significantly in the second period of admission.
The current findings are consistent with previous research into the effectiveness of DBT
within an inpatient service (Bohus et al., 2004) with both patients and clinicians indicating a
significant reduction in symptoms including impulsivity, disturbed relationships, aggression
to objects, and self-harming behaviours. The HoNOS-Secure ratings indicated a significant
decrease over the 12-month period, with a medium effect size. The need for secure provision
remained consistent over the first 6 months as the individuals worked to reduce their levels
of impulsivity with regards to aggression (as rated by the OAS), and then over the second
6-month period, once OAS scores had reduced, so the level of physical security could be
reduced and the patients typically move to less secure areas of the unit with increased levels
of leave.
One major difference between the current study and that conducted by Bohus et al. (2004)
is that the latter recruited outpatients who, for the purpose of the study, were brought into
an inpatient setting. The pre-admission GAF scores of patients in the Bohus study was 48.5,
 Evaluation of low secure DBT treatment 687

falling in the category of “Serious symptoms” of suicidal ideation. The patients in the current
study had an initial GAF score of 5.7, which falls in the “Persistent danger of severely hurting
self or others”, indicating that the patients in the current study were at a far lower level of
psychological functioning. The patients admitted in the current study were already detained in
various secure hospital settings requiring high levels of nursing observation and psychotropic
medication to manage their parasuicidal behaviour and level of aggression towards others.
Because of the risks indicated patients were deemed to need detention under the MHA (1983
amended 2007) in a low secure placement. However, despite their detention under the MHA
(1983 amended 2007) we “actively involve them in the decision” (p. 388 NICE guidelines,
2009) to be admitted into the unit and commit to the DBT programme. The current study
reflects findings from a previous naturalistic, within-groups study of DBT for women in secure
care. Low et al. (2001) similarly found, in a study of 10 women in a high secure setting, that
rates of self-harm reduced and there were significant improvements in symptoms. The current
study adds information about reductions in externally directed aggression
In accord with Low et al. (2001), participants in the present study were not discharged after
completing the 12-month treatment. The current study indicates steady progress within the
12-month period, but change was not sufficient that patients were discharged after 12 months
of treatment and all stayed in the programme after 12 months of treatment. Coid, Kahtan,
Gault, and Jarman (2000) have indicated that women in secure psychiatric care often have
longer lengths of stay than men. This is consistent with the Butler Committee findings (1975)
that the average length of stay in medium secure settings is 2 ½ years.
The purpose of the Service is to establish behavioural control, for a difficult to manage
patient group with symptoms that are “problematic, persistent and pervasive” (Ministry
of Justice, 2011), by reducing threats to life and other behaviours that require inpatient
hospitalization (Stage 1 DBT treatment). Swenson et al. (2001) commented that within
inpatient settings the behaviours often being targeted to reduce aggression (towards self and
others) are reinforced. As well as needing physical security, patients with BPD admitted to a
low secure unit also need clear behavioural boundaries within the unit programme that do not
have the paradoxical effect of increasing the risk of self-injurious behaviours and aggression
towards others.
The results of the current study indicate a reduction in risk behaviours, suggesting that clear,
structured, joined-up low secure services can help patients to develop increased behavioural
control, which in turn allows the low secure unit to meet the goals outlined by the draft Low
Secure Services commissioning guide (DoH, 2012). This guide suggests that low secure ser-
vices should provide care and treatment within a safe, secure environment. Full consideration
needs to be given to issues that surround risk to the patient and others via the adherence to
operational policies, as well as ensuring procedural, relational and physical security needs are
met to enable the patients to move through the pathway of care (DoH, 2012).
The overall objective is that at the end of the first year in the current treatment programme,
patients will generally need less physical security to manage their behaviours. The majority of
patients will not be engaging in self-harming behaviours despite having increased freedoms:
unescorted time away from the unit; unsupervised access to their bedroom; and beginning to
self-cater. There is a need, however, for additional work at this stage to help the patients to
begin to consider ways in which these skills can be generalized to enable them to demonstrate
their skills in a greater number of situations (e.g. fully self-medicating and self-catering,
significant periods of time spent away from the unit in vocational/educational pursuits).
688 E. Fox et al.

NICE clinical guidelines (Borderline Personality Disorder: treatment and management,

2009) suggest a key priority is to “explore treatment options in an atmosphere of hope and
optimism” (p. 379). The increasing evidence base for DBT programmes, as well as patients
seeing their peers getting increased freedoms, allows patients admitted to the unit to be more
hopeful about recovery.
In an inpatient setting it is difficult to know which elements of change are due to DBT and
which result from the rest of the programme, including the structure, boundaries, trained staff,
and occupational therapy pathway of care (Lee and Harris, 2010). However, the structure and
principles within DBT marry well with the unit programme. Further, the current study meets
the seven basic principles for the effective treatment of patients with Borderline Personality
Disorder as outlined by Gunderson (2011), which includes: the need for the patient to have
a primary clinician (the individual DBT therapist); the need for a therapeutic structure (DBT
Skills groups, the occupational therapy programme and relational, physical and procedural
security); the need for the clinician’s support of the patient (met via DBT skills coaching,
individual DBT therapy, and the key worker); need for the patient’s involvement in the
therapeutic process (care plans and commitment to DBT treatment); need for the clinician’s
intervention (DBT skills groups, individual DBT therapy and key worker sessions); need
for the clinician to deal with the patient’s suicidal threats or self-harming acts (targeted in
individual DBT therapy sessions); need for clinician self-awareness and readiness to consult
with colleagues (as met by the provision of weekly DBT consultation and weekly nursing
group consultation/supervision). It is considered that the unit follows these principles, with
results indicating that a structured low secure programme, with a strong psychological model,
active staff and patients, and robust relational and procedural security, can contribute to a
significant reduction in self-harm, aggression and reported symptoms of BPD over 12 months.
Although the study demonstrated a reduction in parasuicidal behaviours and self-reported
symptoms, there is a limitation related to the extent to which findings can be generalized to
independent living because of the ongoing need for hospitalization. Further, the study only
captured the patient’s first year of treatment despite the average length of stay (collated
from our records) being just over 2 years for all patients discharged from the unit. It is
acknowledged that while DBT is the core psychological treatment being offered it is not
in isolation. Therefore the findings cannot be attributed to DBT alone, rather to the entire
treatment package being offered, which includes occupational therapy sessions (Lee and
Harris, 2010), nurse-led sessions that include regular exercise sessions, clear procedural,
physical, and relational structures of security as well as pharmaceutical interventions. A final
limitation is that there was no control group for the current study; although participants’
previous treatment programmes had not resulted in behavioural control, there is the possibility
that given the patients’ commitment (i.e. motivation) to the treatment that they would have
fared equally well in other settings. It is intended that future studies will look at the patients’
perceptions of DBT being delivered in a Low Secure setting and an outcome evaluation of all
patients discharged from the Service.

Acknowledgements
The authors would like to thank David Nevison-Andrews for having the foresight to start a
database and Clive Long for his support and helpful comments on previous drafts.
 Evaluation of low secure DBT treatment 689

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